It was a 5:30 am start for the 'brave' ones as Dr. Lieberman, Lance and I went on a four mile run on the dark and deserted roads of Mbarara. The stars were still shining, the air still and silent, save for the sound of our shoes hitting the ground and the occasional scrapes of our shoes as we try and avoid the numerous bumps and potholes... 7:00 am and we were all ready for breakfast and soon after headed over to the hospital for our first real day of work, with orthpaedic and plastic surgery cases already scheduled for 8:00 and Dr. Lieberman's spine clinic (aka “the penalty box”) scheduled for a 9:00 am start. Dr. Lieberman, Gorlick and I took some time to come up with a game plan for the day before we headed to our consult room. We were a little taken back by the multitude of patients eagerly and impatiently waiting in the hall. We were off to a slow start as patients constantly walked into the closed consult room interrupting ongoing interviews much to our dismay, but they eventually got the point after some stern instruction and the interruptions ceased. We quickly picked up the pace, seeing about 43 cases for the day, many of them follow-up cases from years past... I later on wandered into the O.R theaters and quickly got recruited by Dr. Kerner to help transport Nadine, a 28 year old burn victim who had just undergone an extensive 5 1/2 hour surgery to debride her infected wounds. After some quick planning, and the recruitment of extra hands, we transferred her into a gurney and prepared to transport her to the ICU, almost failing to notice the four new-born babies lying side by side with one’s head next to its neighbors feet. They lay in a single incubator in the corner of the room that had apparently started off empty at the beginning of the day! Nadine, the burn victim, was Dr. Kerner's second surgery patient of the day, the first being a little boy with an eyelid injury sustained from a motorcycle accident. After dropping Nadine off at the ICU, Dr Kerner discussed some post- op management and pain medication options for Denise, settling on some meperidine, as some staff hurried to purchase some morphine to assist with her longer term pain management. She quickly discussed and decided on the line-up for the next day's operations with Dr. Marvin, one of the local doctors. We headed back to the O.R and I took in a quick peek into one of the theaters as Drs. Scharschmidt, Owusu, Fisk and Lubis along with Sherri and Lance worked on their last Ortho patient of the day, intending to fix his multiple leg and foot fractures that had been sustained from a boda-boda (motorcycle taxi) accident. They settle on an external fixator (pins and bars outside the leg) for his femur after discovering a serious, extensive and non-salvageable infection within his lower leg and foot. The plan is to recommend a BKA (below the knee amputation) for the next day after having the chance to discuss it with his family. They quickly wind down; this had been their seventh case of the day, having also ran a concurrent clinic, seeing 27 patients! We slowly assemble after the rest of the groups finish off their work for the day and head back to the hotel at 9:30 pm, ordering some late dinner, then trying to curb our impatience and hunger by each reflecting on our lessons of the day- this being one of our daily rituals. A common theme for the day was the importance of resourcefulness in a setting like this, realizing that we should not take for granted all the resources that are afforded to us at the health care facilities back home and also how much can be accomplished with so little. We slowly wind down after dinner and head over to bed, ready to do it all over again the next day… QOTD: I’m here to pay for my sins- Lance at 05:27 a.m while lacing up his running shoes. Runner up QOTD: ‘Have fun in the penalty box’- Dr. Mark Kayanja’s early morning text message to Dr. Lieberman

‘There must be an easier way to get to school’

Dr. Lieberman and Emmanuel reminiscing over pictures from the 2006 mission

Drs Scharschmidt and Fisk being innovative

Dr. Owusu trying to find the spine with an extensile approach from the femur

London was once again the meeting point for most of the Uganda Spine Surgery Mission team members, though the time spent there was just a short layover. The team, boasting members from London, Texas, Ohio, and Toronto boarded the long eight and a half hour flight from London Heathrow to Entebbe, Uganda. I, the last team member anxiously and excitedly awaited their arrival along with our local bus drivers. After pondering how we were going to fit all our equipment and luggage in our one bus, we began a calculated and concerted effort to try and do just that. After a little while, we were able to fit everything with some (little) room to spare! 1:30 am, after taking a quick moment to relax and refresh, we took in the fresh night air and began our long, tiring, but purposeful 5 and a half hour drive down to Mbarar. At 6:30 am, we arrived, checked in, and after a quick hour and a half nap for some, were back at it for 9 am. We grabbed breakfast and left to unload our equipment and set up at the hospital. After hours of unloading equipment the orthopedics/trauma team, led by Dr. Thom Scharschmidt, and the plastics team led by Dr. Elizabeth Kerner walked through the ward to meet and select prospective surgery candidates. Dr. Lieberman and Dr. Owusu also selected four prospective patients for spinal surgery- two boys, Ezekiel and Frank with suspected congenital kyphosis, Denise, an 18 year old with severe kyphoscoliosis and Enid, a 23 year old with a TB infection affecting her lumbar spine. We booked her for an anterior corpectomy and reconstruction for Wednesday. We concluded our time at the hospital at 4 pm with even more unpacking. During the process we blew some fuses from the newly donated Stryker drills, but finished our unpacking nevertheless. The team was tired and running out of steam after a long day’s work and only having only eaten breakfast. After what was supposed to be a short journey into town, we settled down for some cold drinks, toasting to a successful first day and even more fulfilling couple of weeks to come. We headed into the hotel for a delicious buffet dinner, and some well deserved rest. Quote of the day -'ouch that was my nipple'- Tom G. exclaimed, grazing his nipple as he helped unload some heavy bins from the bus! Runner up quote of the day: ‘That is true love’- Sherri observing the subjects of photograph 1.

A woman props up a man into a comfortable position as he awaits an assessment for his shattered foot.

The team picture just after landing in Entebbe

Transporting our equipment into the O.R

Dr. Kerner dressing a burn victim.

Dr. Owusu checking some reflexes on Frank, one of the prospective surgery candidates.

Dr. Scharschmidt studying the Xray of one of his prospective surgery patients.

The team assembles around Dr. Deo as he translates and presents a case to Dr. Scharschmidt and Dr. Fisk, one of his chief residents.

July 27, 2014 I must admit, the last three weeks I was “on edge”. This is the 10th mission. By now I assumed it would be auto pilot. Yet this is the most ambitious Uganda Mission endeavor since its inception. Five teams (3 spine, 1 trauma/joint & 1 plastics team), 28 volunteers, 3 shipments, and shipping containers that I can’t keep count of. This morning came and a new realization came with it, I can’t prepare any more. The mission is now. After a week of packing, sorting, collecting and re-packing, Lance and his wife came with their minivan to my house to pick up the containers and myself. The rest of the team from Dallas, Skylar, Anthony & Sherri met us at the British Airways check in kiosk. Immediately Anthony set the “smooth” tone for the trip. During the check in process, I think he is hitting on the ticket agent, by claiming to have a tattoo of her name “Lydia” on his arm. To my astonishment he scores the team an extra baggage waiver by lifting his Dr Pepper t-shirt to show the name Lydia tattooed on his arm. It remains to be seen how smooth he is when faced with the overwhelming spine pathology he is soon to witness. The flight to Heathrow was uneventful, and Heathrow security as non-compliant as ever. We persevered and made it to the rendezvous at Huxley’s pub in terminal 5. There we were joined by Liz, then Tom S., Tom G. & Erica, closely followed by Nur. As security delayed us we really had no time to reacquaint or even meet the new team members. Just as Heathrow security was unwavering in its reputation, Zvi was too in his arrival. He strolled into Huxley’s, with his duty free bag, with his ever calming demeanor, about 30 seconds after I had made the decision that we can’t wait for him any longer and need to proceed to the boarding gate. With all team members accounted for, I was no longer on edge and ready for the second nine hour flight. The arrival at Entebbe was uneventful and on time. As predictable was the fact that one shipping container with the total joint equipment did not show up. Tom S. hustled to the baggage claim attendant while we began loading collecting the bags and containers to load onto the bus. As we exited the terminal I was very much relieved seeing the Mbarara Health Services bus and the remaining team member Joseph. Joseph even had the bottled water and ground nuts I had asked him to procure for the trip to Mbarara. Those nuts were even more flavorful now that the team was intact and we were on our way. For those following this blog, stay tuned, visit often and send messages. We thank you all for your support to date.